tbuckley/cabot-search huggingface dataset:
Abstract 11462: Alcohol Septal Ablation vs Surgical Myectomy for Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis
Authors: Mahmoud El Iskandarani, Islam Shatla, Mohamad Kassab, Timir K Paul
Journal: Circulation (2022)

Introduction: Surgical Myectomy (SM) is the gold standard treatment for hypertrophic obstructive cardiomyopathy (HOCM). However, alcohol septal ablation (ASA) has emerged as an alternative option for selected patients. Nonetheless, the long-term efficacy and safety of ASA have been debated in recent years. The aim of this metanalysis is to evaluate the long-term outcomes of ASA vs SM in HOCM patients. Hypothesis: ASA is a safe and effective alternative to SM in HOCM. Methods: : Unrestricted searches of the PubMed, EMBASE, and Cochrane databases from inception till June 1, 2022, for studies comparing long-term outcomes of ASA with SM in HOCM patients. Relevant data were extracted and analyzed using Revman 5.3 software. Odds Ratio (OR) and 95% Confidence interval (CI) were calculated using the random-effects model. Results: : A total of 12 retrospective studies were included examining 7,599 HOCM patients (2,010 ASA vs 5,589 SM). After a mean follow-up of 5.04 years, all-cause mortality was similar between the two groups (OR 1.18; 95% CI 0.60-2.29). However, ASA was associated with high rates of reinterventions (OR 15.68; 95% CI 6.71-36.61), and pacemaker insertion (OR 2.74; 95% CI 1.39-5.41). Conclusions: Although there was no difference in mortality between ASA and SM, ASA was associated with higher rates of reinterventions and pacemaker insertion in long-term follow-up. Therefore, the selection of septal reduction therapy in HOCM should be individualized and should be performed in a comprehensive center after detailed risk and benefits discussions with an experienced team.
Abstract 11454: Sarcopenia Evaluated by Thoracic Computed Tomography is Associated With Higher Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement
Authors: Ian Persits, Saeid Mirzai, Jerry Estep, Po-Hao Chen, Grant W Reed, Wai Hong W Tang
Journal: Circulation (2022)

Introduction: Sarcopenia is associated with worse outcomes in various clinical situations. Traditional markers of strength and frailty have been used for pre-operative risk stratification in transcatheter aortic valve replacement (TAVR). However, the availability of computed tomography (CT) scans provides an opportunity to obtain direct skeletal muscle measurements. Hypothesis: We hypothesized that sarcopenia would lead to worse outcomes in patients following TAVR. Methods: Patients undergoing TAVR between January to July 2018 with pre-procedural chest CT were included. Semi-automatic measurements of skeletal muscle area (SMA) were made at the twelfth thoracic vertebra. SMA was normalized by height to obtain skeletal muscle index (SMI, cm 2 /m 2 ). Sarcopenia was defined as the lowest sex-stratified SMI tertile. Strength and functional testing data had been collected as part of the routine pre-TAVR evaluation. The primary outcome of interest was all-cause mortality. Results: A total of 76 patients were included, 26 sarcopenic based on SMI. Table 1 shows comparisons between the groups. During a median follow-up of 1496 (1401-1562) days, 10 (38.5%) deaths occurred in the sarcopenic group and 9 (18.0%) in the non-sarcopenic group. Figure 1 demonstrates this significant difference by Log-Rank testing (p=0.042). The secondary outcomes of length of stay and 30-day readmission did not differ between the groups on unadjusted comparison. Conclusions: Sarcopenia was associated with increased mortality in patients who underwent TAVR. A larger study is underway to assess the potential of muscle measurements serving as an additional pre-operative risk stratification tool.
Abstract 11658: Acute Coronary Syndrome After Insect Bite: A Systematic Review
Authors: Tanuj Gupta, violeta capric, Jessica Celenza-Salvatore, Nader Jamaleddine
Journal: Circulation (2022)

Arthropod and insect bites/stings have been associated with the development of Acute Coronary Syndrome (ACS) in prior case reports. In this systematic analysis, we review 57 reported cases of ACS in patients that were exposed to arthropods, bee stings or insect bites, and provide a summary of these findings in Table 1. We then discuss Kounis Syndrome Type 1 or Type 2 as the proposed mechanism by which myocardial ischemia develops in this subset of patients, and the implications of this diagnosis on management. Kounis Syndrome Type 1 develops due to mast cell activation and histamine release provoking vasospasms and inducing myocardia injury in the absence of underlying coronary artery disease, as demonstrated in Figure 1A. Kounis Syndrome Type 2 develops due to inflammation induced plaque rupture and subsequent thrombus formation, as demonstrated in Figure 1B. In general, Kounis Syndrome should be suspected in patient’s presenting with the appropriate exposure, an allergic or anaphylactic response and/or unremarkable coronary angiogram (specific to Type 1). Once suspected, the use of coronary artery vasodilators, antihistamines, steroids and possibly Epinephrine should be considered in management. In this review, it was discovered that approximately 50% of cases received management consistent with Kounis Syndrome (targeted to allergic/anaphylactic symptoms) with appropriate clinical response, yet only 12% received the formal diagnosis, indicating this condition is underdiagnosed. Furthermore, 40% of patients that underwent coronary angiogram did not have CAD, indicating a possible Type 1 (vasospastic) etiology of ACS that may benefit from more targeted therapy.
Abstract 11672: A Case of Postpartum Seizure, Cardiac Arrest, and Shock
Authors: Christopher W Hoeger, Alex Levy, Loryn Feinberg, Scott Shainker, Marwa Sabe
Journal: Circulation (2022)

Cardiogenic shock (CS) in the peripartum period is associated with significant morbidity and mortality. Treatment of CS by specialists in high-volume centers is associated with improved outcomes. A healthy 34-year-old pregnant woman underwent planned cesarian section delivery for placenta previa at a community hospital, which was complicated by postpartum hemorrhage treated with methylergonovine, tranexamic acid, and carboprost. One hour later, she was hypertensive, tachycardic, and had a generalized seizure followed by hypoxemia and pulseless electrical activity. She was persistently hypotensive after resuscitation. An echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 25%. She was transferred to our cardiac intensive care unit (CCU) for consideration of mechanical circulatory support (MCS). The patient arrived at the CCU on multiple vasopressors and inotropes. The advanced HF, CCU, and maternal fetal medicine teams assessed the patient on arrival. Bedside right heart catheterization demonstrated right atrial pressure of 6 mmHg, pulmonary arterial pressure of 22/17 mmHg, pulmonary capillary wedge pressure of 10 mmHg, and Fick cardiac index of 2.5 L/min. BP was improving and vasoactive agents were weaned. The bleeding risk of anticoagulation for MCS after postpartum hemorrhage was thought to outweigh the potential benefit of MCS with normal filling pressures and weaning of vasoactive agents, thus MCS was not deployed. An electroencephalogram revealed status epilepticus, and magnetic resonance imaging of the brain was suggestive of posterior reversible encephalopathy syndrome with hemorrhage secondary to cerebral vasospasm. TTE on hospital day 4 showed normalization of biventricular function, and she made a full neurologic recovery and was discharged home on hospital day 15. Given the normalization of cardiac and neurologic function with supportive care only, her shock was attributed to methylergonovine-induced cerebral vasospasm leading to seizures with subsequent respiratory and cardiac arrest and myocardial stunning. This case demonstrates the importance of rapid team-based diagnostic assessment of peripartum patients presenting in suspected CS to appropriately triage the use of MCS.
Abstract 11660: Case Report: Stymied by the Stemi, an Un-Emblematic Pulmonary Embolism
Authors: Jothika T Tamizharasu, Carter W English, Surabhi M Atreja
Journal: Circulation (2022)

Introduction: Diagnosing a pulmonary embolism (PE) can be challenging, especially when it presents as another “can’t miss” diagnosis like acute coronary syndrome. Although electrocardiogram (EKG) abnormalities can be seen in many PE presentations, rarely are ST elevations noted. We describe a case report of PE presenting as STEMI. Case presentation: A 71-year-old woman with hypertension, hyperlipidemia, type 2 diabetes mellitus, and morbid obesity presented to the emergency department with chest pain radiating to the jaw along with shortness of breath. On initial presentation her heart rate was 110 bpm, respiratory rate 40, 84% SpO2 on room air, and blood pressure 150/84 mmHg. EKG showed ST elevation in anterior leads V1-V2 and reciprocal changes of ST depression in lateral leads I, aVL, V5-V6. Serial troponins were elevated and she underwent left heart catheterization which showed non-obstructive coronary artery disease and hyperdynamic left ventricular function. Right heart catheterization (RHC) showed an elevated mean pulmonary artery pressure of 49 mmHg, and pulmonary artery pulsatility index was 2.2, suggestive of right ventricular dysfunction which prompted an urgent CT pulmonary angiogram and transthoracic echocardiogram. The CT revealed extensive pulmonary embolism and echocardiogram demonstrated dilated right ventricle with hypokinesis and akinetic right ventricular free wall. A left lower extremity ultrasound revealed deep vein thrombosis. Discussion: This patient depicts an uncommon presentation of acute PE masquerading as acute coronary syndrome. Her case was diagnostically challenging as her EKG findings were not consistent with those typically seen in acute PE. Review of the literature reveals only a handful of case reports of a PE appearing to be a STEMI. Although rare, clinicians should entertain the idea of PE when presented with ST elevation and no culprit lesion and a careful RHC may be useful in establishing diagnosis.
Abstract 11412: Use of Guideline-Directed Medical Therapies After Hospitalization for Heart Failure: Real-World Insights From EVOLUTION HF
Authors: Biykem Bozkurt, Gianluigi Savarese, Samuel Adamsson Eryd, Johan Bodegard, Cindy Khordoc, Marcus Thuresson, Orly Vardeny, Takuya Kishi, Lars H Lund
Journal: Circulation (2022)

Introduction: In the period after hospitalization for heart failure (hHF), patients are at high risk of cardiovascular death and rehospitalization. Guidelines for heart failure with reduced ejection fraction (HFrEF) emphasize early initiation of four guideline-directed medical therapies (GDMTs: beta-blocker, renin-angiotensin system inhibitors [RASis] or angiotensin receptor neprilysin inhibitor, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter-2 inhibitors [SGLT2is]). However, real-world data on the concurrent use of these four GDMTs are scarce, particularly after hHF. Methods: EVOLUTION HF is an observational, longitudinal cohort study using claims and electronic health record databases to assess the use of GDMTs in patients with a recorded hHF. We report KM estimates of initiation of GDMTs in the 3 months following an incident hHF (index date) with no prior HF diagnosis. Use of GDMTs in the month before the index hHF (e.g. RASis for hypertension) was counted as use at index. The study period started after approval of the first SGLT2i (dapagliflozin) for HFrEF in each country. Results: Overall, 49 807 patients were included. Ejection fraction was not recorded for most patients. Mean KM estimates for use of four GDMTs at 1 and 3 months post hHF discharge were 6.5% and 7.8% (Japan), 8.0% and 11.7% (Sweden), and 0.9% and 1.7% (USA), increasing with each consecutive calendar quarter (Figure). This trend was largely explained by an increase in SGLT2i use. In the first and last quarter of each study period, KM estimates of SGLT2i use at 3 months were 15.3% and 21.2% (Japan), 7.2% and 32.6% (Sweden), and 2.3% and 4.8% (USA). Conclusions: Uptake of four GDMTs remains low, highlighting an urgent need for earlier and increased GDMT initiation to manage severe risks, especially in the vulnerable post-hHF period. Data on SGLT2i benefits have led to a slow yet steady increase in SGLT2i early use post hHF as part of a four-GDMT approach to treating HF.
Abstract 11256: Endothelial-to-Mesenchymal Transition (endMT) is a Driver of Endothelial Cell Heterogeneity in Human <i>in vitro</i> and <i>ex vivo</i> Atherosclerotic Plaques
Authors: Maria L Adelus, Casey E Romanoski
Journal: Circulation (2022)

Atherosclerosis begins with endothelial cell (EC) dysfunction. However, the relationship between single-cell (sc) EC profiles in vitro and in human atherosclerotic plaques is unexplored. Herein, we exploited sc EC transcriptomes from human plaques and related them to in vitro models of inflammation and angiogenesis, which we expected to be relevant. To curate a gene expression profile of ECs found in human atherosclerotic plaques, we performed a meta-analysis of three publicly available human scRNA-seq datasets comprised of 17 coronary and carotid specimens. In parallel, we generated a Multiome in vitro dataset composed of 6 primary human aortic ECs (HAECs), under three experimental conditions: (1) untreated control, and (2) IL-1B-treated (10ng/mL for 1 hour) HAECs on typical gelatin-coated plastic dishes; and (3) untreated HAECs grown on Matrigel to mimic angiogenesis. Five clusters represented the HAECs from all three in vitro conditions. Pathway enrichment analysis revealed that Matrigel-grown ECs (cluster 1) were largely distinguished by Signaling by Rho GTPases, Miro GTPases and RHOBTB3 (R-HSA-9716542; Log10(P) -45.96), while untreated and IL-1B-treated ECs (clusters 0 and 2) were distinguished by regulation of cell adhesion (GO:0030155; Log10(P) -39.92) and Cell Cycle (R-HSA-1640170; Log10(P) -32.2). Of note, clusters 3 and 4 were comprised of HAECs from all 3 conditions and appeared to represent partial and complete endMT, respectively. Cluster 3 and 4 were characterized by greater expression of mesenchymal markers (COL1A1, COL1A2, COL3A1, TAGLN, VIM, and CDH2), while cluster 4 was additionally characterized by a reduction in EC markers (ERG, CDH5, PECAM1). When in vitro HAEC and ex vivo plaque data were integrated, cells from in vitro cluster 4 clustered with vascular smooth muscle cells from human atherosclerotic plaques. Taken together, these results reveal that HAECs are heterogeneous both in vitro and ex vivo atherosclerotic conditions. Since endMT occurs spontaneously at some minor frequency in vitro (~5%) with expression signatures observed in vivo, these data establish a clinically relevant in vitro model to understand the molecular processes driving endMT.
Abstract 11715: Valve-in-Valve Transcatheter Aortic Valve Implantation for Early Valve Degeneration
Authors: Nikhil Gupta, Abdulrahman Dia, Nikhil Singh, Alejandro Plana, Mikail Siddiki, Nicole Prabhu, Ali Alsaad, Sandeep Nathan, Atman Shah, John Blair
Journal: Circulation (2022)

Case Presentation: A 64-year-old woman with presented to the hospital with chest pain and hypotension during hemodialyis. Three months prior to presentation, she had underwent transcatheter aortic valve implantation (TAVI) and received a 26 mm CoreValve Evolut Pro (Medtronic, MN) for severe aortic stenosis. She was admitted to the cardiac intensive care unit and underwent diagnostic testing. Transthoracic echocardiography demonstrated a new mean transaortic valve gradient of 55 mm Hg (Figure 1A), increased from her post-procedural gradient of 12 mm Hg. Despite empiric treatment with heparin anticoagulation and antibiotics, the patient did not improve clinically. CT imaging did not reveal valve thrombosis, endocarditis, or any other structural deformities (Figure 1B), and the patient’s mean transaortic valve gradient worsened to 73 mm Hg. After a multidisciplinary discussion, a decision was made to offer a valve-in-valve TAVI for early valve degeneration with a 23 mm Sapien S3 (Edwards, CA) valve (Figure 1C). After her procedure, the patient’s symptoms resolved and she was discharged from the hospital. The patient’s mean transaortic valve gradient improved to 12.6 mm Hg at her 4 month follow up visit (Figure 1D). Discussion: Early TAVI valve dysfunction is typically attributed to thrombus or infection of the valve. Here we present a case of valve dysfunction that was not related to either of these etiologies. Delineating the cause of her valve dysfunction was vital to her therapeutic decision making. Since the patient was not a surgical candidate, valve-in-valve TAVI was offered when thrombus and endocarditis were eliminated as the etiology of her valve dysfunction.
Abstract 11379: Libman-Sacks Endocarditis Mimicking Intracardiac Tumor in a Patient With Systemic Lupus Erythematosus and Secondary Antiphospholipid Syndrome
Authors: Dayana Orozco -Sepulveda, Jorge Eduardo Hernandez del Rio, RAMON E SANTALO, Tomas Miranda - Aquino
Journal: Circulation (2022)

A 43-year-old woman, with history of SLE for 12 years and secondary APS for 10 years. Hospitalized in 2016 by pulmonary embolism, finding on that occasion the presence of intracardiac mass in the right atrial, at that time, she was pregnant and had full anticoagulation with LMWH until the end of the pregnancy. Since then, in treatment with azathioprine, hydroxychloroquine and acenocoumarin irregularly. She presented to the ER with a 21-day history of abdominal distention and diffuse pain, dyspnea at rest, and bilateral lower extremity pitting edema. On presentation patient was normotensive and tachycardic, in anasarca and with a loud holosystolic murmur at the parasternal border, in fifth intercostal space. Was admitted for acute heart failure. In TTE, the persistence of the right atrial mass dependent on interatrial septum with greater growth than the previous one was observed. The tumor protruded within the entrance tract of the right ventricle during diastole and during systole a doble jet of severe tricuspid regurgitation is observed. The tricuspid valve was thickened. A contrasted enhanced cardiac magnetic resonance confirmed the presence of the tumor described above without contrast uptake. The patient underwent mass excision surgery with preoperative diagnosis of atrial myxoma. Microscopic examination of the excised material revealed dispersed lymphohistiocytic infiltrate and thrombi without evidence of microorganisms, compatible with Limban-Sacks endocarditis. Because of the size and location of the lesion, Libman-Sacks endocarditis was considered highly unlikely. Only few cases of a vegetation simulating an intracardiac mass have been reported and in these patients analysis of serologic markers showed that lupus anticoagulant was positive, anticardiolipin antibodies IgM-G and antiphospholipid antibody were high.
Abstract 11150: The Effect of Eicosapentaenoic Acid and Docosahexaenoic Acid on Neutrophil/Lymphocyte Ratio, a Marker of Inflammation, in Subjects With Coronary Artery Disease: Results of a Randomized Trial
Authors: AbdulAziz A Asbeutah, Abdulaziz Malik, Francine K Welty
Journal: Circulation (2022)

Background: The neutrophil/lymphocyte (N/L) ratio increases with the systemic inflammatory response due to an increase in neutrophils and decrease in lymphocytes with systemic inflammation. An elevated N/L ratio has been associated with an increased risk of cardiovascular disease (CVD), cancer and mortality. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) decrease levels of high sensitivity C-reactive protein (hs-CRP), the gold standard inflammatory marker, when levels of hs-CRP are elevated. Randomized trials have also reported a decrease in CVD events with EPA. The mechanism for this benefit is unclear. Objective: To examine the effect of high-dose EPA and DHA supplementation on inflammation as measured by the N/L ratio in the setting of low levels of hs-CRP. Methods: A total of 242 subjects with stable coronary artery disease on statin treatment were randomized to 3.36 g EPA+DHA daily or none. N/L ratio and the monocyte to lymphocyte (M/L) ratio were measured at baseline and 1 year. Results: Mean (SD) age was 63.1 years (7.7); mean (SD) LDL-C: 77.8 mg/dL (27.3); median [IQR] TG: 117.5 mg/dL [81.3,166.8] and median [IQR] hs-CRP: 0.75 mg/L [0.40,2.5]. Those on EPA+DHA had a 2.2% reduction in N/L ratio (P=0.014) at 1 year compared to those not on EPA+DHA who had a 12.2% increase (Figure) (between group P= 0.007). There was a trend toward benefit with the M/L ratio (P=0.078). Conclusion: High-dose EPA+DHA decreases systemic inflammation as reflected in the N/L ratio even with low hs-CRP levels. This is a new finding which suggests that under conditions of generally low levels of inflammation in terms of hs-CRP levels, the N/L ratio may be a more sensitive measure of underlying inflammation than hs-CRP and should be considered as an additional marker in future studies of omega-3 fatty acids. If a decrease in inflammation by N/L ratio were accompanied by a clinical decrease in CVD events, this would assist in determining a plausible mechanism of action.
Abstract 11304: Spectrum of Clinical Response in Atrial Tachyarrhythmias Identified by Spatiotemporal Synchronization of Electrograms
Authors: Prasanth Ganesan, Brototo Deb, Ruibin Feng, Miguel Rodrigo, Samuel Ruiperez-Campillo, Albert J Rogers, Paul L Clopton, Paul J Wang, Wouter-Jan Rappel, Sanjiv M Narayan
Journal: Circulation (2022)

Introduction: A clinical spectrum exists for atrial tachyarrhythmias, wherein tachycardia (AT) often responds to ablation, some patients with atrial fibrillation (AF) respond well to ablation, and others do not. It is undefined if this clinical spectrum can be predicted pathophysiologically. Hypothesis: We hypothesize that the size of regions within which electrograms (EGMs) show repeating shapes also synchronized in time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. Methods: We studied N=160 patients (35% women, 65.0±10.4Y) of whom (i) N=150 were AF patients propensity-matched for those whose AF terminated by ablation (N=75; “Term”) and those which did not (N=75; “Non-term”); (ii) N=10 with AT. All patients had mapping by 64 pole baskets to identify areas of repetitive electrical activity in shape and timing (REACT, range 0 to 1), by correlating unipolar electrograms (EGMs) in 2x2 grids iteratively across the atria (Fig A&amp;B). Results: Synchronized regions (REACT) fell from AT to AF Term to AF Non-term (0.63±0.15, 0.37±0.22, 0.22±0.18, p&lt;0.001, Fig C&amp;D). On ROC analysis, AUC for predicting AF termination was 0.70 ([0.61, 0.78] 95% CI). Simulations revealed a nomogram in which increasing REACT represented increasing variability in clinical EGM shape and timing. Unsupervised machine learning of REACT plus 50 variables yielded 4 clusters of increasing risk for AF termination (p&lt;0.01, chi-sq) but clinical profiles alone were less predictive (p&lt;0.001). Conclusions: The area of synchronized EGM shape and timing within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any specific mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.